Submit a Referral

Referring patients is simple. Download our fillable PDF forms below, complete the required information, and submit to us—we'll handle everything from there.

Fax (562) 402-4629 or email info@mercyinfusion.com with the following:

Patient demographic sheet, Insurance card (front & back), Labs, chart notes, & relevant test results. We take care of the rest!

Referral Forms:

Gastroenterology

Neurology

Dermatology

Pulmonology

Rheumatology

Immune Globulin Autoimmune Disorder 

Immune Globulin Maternal Fetal Medicine 

Immune Globulin Primary Deficiency 

Immune Globulin Transplant 


Need a different form? We’re here to help!

If you would like to see a referral form that is not listed above, please let us know.

Providers – want to learn more?

Request a visit from a Mercy Infusion representative, and a member of our team will visit your office to discuss our services and see how we can best serve your patients